Wednesday, November 12, 2008

I Was On My Way Out the Door...

I called to Daniel, "time to change your site!" He's pretty much at the point where he is changing it on his own, and I think he likes me there for moral support. I had to leave for yoga class, so if he wanted me there for support, it had to be NOW! So down the stairs he came and said, "don't worry, I don't need you to be here. You can go to class." I said fine, and was going to head out, but turned around to take the insulin out of the refrigerator for him as he's pulling out the other supplies. I had picked up the insulin prescription yesterday at CVS.

As I'm walking over to Daniel with the box, I glance down and see a strange name where Daniel's name should be. I stopped, went back to the fridge and got all three boxes. They don't have Daniel's name on them. I said, "Daniel, there's something wrong. This isn't your insulin."

Daniel said, "I just pulled out the site." He comes to look at the box. "Well, anyway, it's novolog."

I looked at the box, and I looked at Daniel's box from his finished bottle. "It's not the same insulin. The box that didn't belong to us said Novolog 70/30. Not right. Not good.

I grabbed the boxes and the receipts from yesterday and shot over to CVS -- probably a little too fast -- going over in my head what had happened the day before. Picture it -- a long line, later in the evening. Two or three pharmacists busy in the back, two people working the registers. I'm finally at the front of the line, and the girl behind the register finishes ringing up her customer, then folds her arms down on the counter and says, "God, I just want to go home!" I smile, thinking, yeah, it's been a long day, I want to go home, too.

I give her Daniel's name and she goes to look for the prescriptions (keytone strips and novolog). She gets the strips and then looks in the refrigerator for the novolog. She looks and looks and I say to her, "look in the door of the refrigerator," but she doesn't hear me and can't find it. She walks back over to the pharmacist with the paperwork in hand, and the pharmacist says, "It's in the fridge! Look in the door!" So register girl goes back to the fridge and looks in the bottom, and in the back, but NOT IN THE DOOR.

I call out a little louder, "LOOK IN THE DOOR." She finally does. Picks up three boxes rubber-banded together, turns them around, looks them over, and says, "okay," and puts them in the CVS pharmacy bag. I took them home.

So I flew back there tonight and thank goodness there was no line. Register girl is behind the counter again, and I restrain myself from leaping over the counter and into her face. I explain that I received the wrong prescription, the wrong medication, and that my son needs his insulin NOW. She goes back into the fridge, pulls out three more rubber-banded boxes, and says, "Daniel, right?" YES.

I get the boxes and triple check them. They are Daniel's. She smiles at me. "Okay! All set!"

I dropped the boxes off at home and hit the road to try to make it to yoga. On the way I called CVS and spoke to the pharmacist and explained what happened. I said that it was lucky I happened to grab the boxes and look at the name. Daniel wouldn't have looked, he would have just injected. I found out later that 70/30 novolog is a combination of fast and slow acting insulin. Daniel only uses fast acting insulin. I don't like to think of what could have happened. The pharmacist said he would remedy the situation.

I hope so. Register girl needs to know that she could have caused an awful problem. Tired as she may be, if she's dispensing medication, she has to focus on what she's doing.

Never walk out of a pharmacy without opening the bag and looking at what they gave you. Check the name, check the medication. You might save your life.


FeltFinland said...

Whoa! Scary!We were once given the wrong asthma inhaler for Aleksi - fortunately it was not a problem. But I will certainly triple check next time I go to the pharmacy for his insulin!

Naomi said...

When I got to yoga class, I told my friend Manuel, who is a pharmacist at a hospital, what happened. He said that you have to make it a habit when taking medicine -- whether at the store or when you get home -- to look at the label. Every time.

At least yoga helped me stop stressing about what could have happened. That was hard to let go!

Cara said...

Been there, done that! Had to go back to the pharmacy. It's not fun because if we weren't so diligent, there could be serious health risks involved. People should pay closer attention.

Isophorone said...

Good help is so hard to find!

Sara said...

I got the wrong brand of strips once, but never insulin. That's scary!